Coast Mountain Expeditions, Ltd.

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TRIP REGISTRATION FORM

Trip selected ______________________________________________________________
Dates ____________________________________________________________________
Applicant's full name ________________________________________________________
Address __________________________________________________________________
City ______________________________________________________________________
Province/State _____________________________________________________________
Postal Code ________________________________________
Phone (Day) ____________________________(Evening) ___________________________
E mail Address_____________________________________________________________
Applicant's Age _________________  Height _______________  Weight ______________

Emergency Contact:
Name ____________________________________________________________________
Address __________________________________________________________________
Phone ____________________________________________________________________
Relation to applicant ________________________________________________________

If applicant is under 19:
Parent's name _____________________________________________________________
Address __________________________________________________________________
Place of employment _______________________________________________________
Work phone _______________________________________________________________

Note: Parents should sign the medical and waiver form. Registration should be accompanied by a letter of endorsement from parent

MEDICAL FORM

Name: ______________________________________ Birthdate: ____________________
Medical insurance plan: _____________________________________________________
Physical condition: _________________________________________________________
Allergies life threatening _____________________________________________________
Allergies non life threatening _________________________________________________
Date of last Tetanus inoculation or booster: _____________________________________
Are you on any medications (prescription or non-prescription)? yes ___ no ___
If yes, please specify: _______________________________________________________
Have you been under a doctor's care in the past 12 months? yes ___ no ____
If yes, please specify: _______________________________________________________
Do you have a chronic dissability or illness:
Epilepsy, diabetes, susceptibility to colds, headaches, nosebleeds, fainting, asthma, hay fever, emphysema, or others:__________________________________________________
History of joint injury (tendonitis, bursitis, sprain, dislocation, or other):
__________________________________________________________________________
Eyesight ___ Excellent ___ Good ___ Fair ___ Poor ___ Glasses* ___ Contacts
*If you are dependent upon glasses for adequate vision, a spare set should be brought with you.
Do you have any physical limitations? __________________________________________
__________________________________________________________________________
Do you feel that you have any psychological limitations? (i.e.. fear of water, fear of heights, etc.) Please explain:_________________________________________________

The above medical information is complete and accurate. If any of the information changes, I will inform the instructors so that the changes can be recorded. I have read the trip outline and physical requirements. I am in good physical condition to participate. I have read the disclosure information and understand the possible hazards that may be encountered on the trip. I agree to adhere to the rules and regulations set up by the leaders of the trip to minimize risk and ensure safety. I have read the Disclaimer of Liability of Coast Mountain Expeditions. Ltd. (Safety and Responsibility, the "fine print") and agree to be bound by its terms and conditions

Signature of Applicant_______________________________________________
Date ________________________

Parent's Signature (if applicant under 19)________________________________
Date ________________________

Coast Mountain Expeditions, Ltd.  Phone (250) 285-2823
MAIL TO: Box 25, Read Island, Surge Narrows, BC, Canada V0P 1W0